The Inside Approach to Outreach Programs Tatia Sheppard

Tatia Sheppard, RN, CCM, CCWS, CMCN (1)

1. Nova Healthcare Administrators

Summary

As health plan participants modify behaviors or adapt to plan changes, new information will emerge. Data analysis needs to be ongoing. Therefore, educational aspects of outreach programs are invaluable. It is important to view plan recommendations and strategies through the lens of the plan sponsor and the plan participant. Employers understand their tolerance for change. And they know their employees best. With the right partner to engage in conversations, each possibility for data review provides another opportunity for conversation around improving plan performance and health outcomes.

Key Points

Reduce inappropriate utilization of Emergency Room (ER) visits Avert complications and prevent readmissions Improve member care needs by linking members to a primary care doctor or specialist to manage care appropriately Identify members for case management opportunities who may need assistance in navigating the health care delivery system, education and support to enhance their understanding of their condition, and treatment to avoid complications/exacerbation

Working in the health care industry has taught me many things. One of the most important lessons: you must have a plan. The key to integrated medical management program success is to help participants coordinate care through the development of an individualized care plan to meet their needs by ensuring the participants have the necessary tools and support to achieve optimum health and improved self-management, in the most appropriate setting and cost-effective manner.

The problem is many members use the emergency room (ER) inappropriately for treatment of non-lifethreatening conditions increasing the cost for unnecessary or inappropriate services. Common barriers include the lack of knowledge, geographical location (ER is closer, no urgent care facility nearby), no Primary Care Physician (PCP) or lack of access and/or knowledge of PCP sick visit process, chronic condition exacerbations, and/or lack of transportation. assist in the development of building program strategies that provide employees with rich benefits while remaining cost-effective for health plans. However, what happens between the data reporting and overall outcomes are the real opportunities to promote change: identifying members who may need assistance in navigating the health care delivery system.

There are three phases to this process: • Understanding the importance of engaging members by assisting them in securing a primary care physician. This increases compliance and reduces the amount of ER visits. • Learning how having real-time conversations with members aids in reducing complications and admissions; Hear how pre and post hospitalization outreach to members also serves as an education resource. • Discovering how adopting strategies based on data can have a positive impact on plan performance and health outcomes.

APPROACH

Emergency Room Utilization and Pre- and Post-Hospitalization Outreach and Engagement The objectives of this program are to reduce inappropriate utilization of ER visits, improve member care needs by linking them to a primary care doctor or specialist, and identifying members for case or disease management opportunities who need assistance navigating the health care delivery system or education and support to improve self-management of their conditions. Through various outreach processes and member participation factors program closure reasoning varies.

Real-Time Conversations and Information Sharing A successful approach to treatment plan compliance include targeted outreach campaigns to plan participants with chronic conditions. Additionally, when clinicians work one-on-one with plan participants, they are able to help them address their needs and address potential barriers to care. Information sharing with physicians can help connect the dots to improve communication with the provider and patient to address behaviors that often result in urgent and emergent care. At Nova, we use our patient health summary (medication, labs, utilization) to bring all of the data points together so clinicians have access to a comprehensive view of each patient. By assessing the member’s understanding of upcoming procedures and admissions, reinforcing the physician’s treatment plan, and assisting with facilitation of appropriate discharge services, pre-and post-hospitalization outreach programs experience greater success in promoting optimal health and reducing readmission.

Adopting Strategies Based on Data Effective plan management begins and ends with data; what matters is what you do with it. When it comes to consuming health plan data, you must keep asking questions. Why is this happening? What is driving cost? Where are plan participants seeking services? How can we manage it? You need a strategic approach to plan analysis. To create the most impact and yield the best outcomes, it is important to remember that the most cost-effective strategies do not fit into the traditional Utilization Management, Case Management, or Engage members by assisting them in securing a primary care physician. This reduces the amount of ER visits. • Conduct real-time conversations with members aids in reducing complications and re-admissions;

Hear how pre and post hospitalization outreach to members also serves as an education resource to improve their understanding of their recovery to support optimal recovery outcomes. • Adopting strategies based on data can have a positive impact on plan performance and health outcomes.

RESULTS

Engaging members, assisting them in securing a primary care physician can reduce the amount of ER. Conducting real-time conversations with members aids in reducing complications and re-admissions; on our end, we get to hear how pre and post hospitalization outreach to members also serves as an educational resource to improve their understanding of their recovery to support optimal recovery outcomes. Adopting strategies based on data can have a positive impact on plan performance and health outcomes.

Below are some results and trends Nova’s plans and our Health Plan Performance Management department have observed from delivering a personal experience to meet plan participants’ specific needs.

In the end, every health plan population has unique challenges that require the right course of action to bring about better health outcomes and sustainable savings. Collaboratively developing individualized care management plans is the key to promoting improved health across the continuum of care. When an individual reaches the optimum level of wellness and functional capability everyone benefits.

ARTICLE INFORMATION

About the Author: Tatia Sheppard RN, CCM, CCWS, CMCN is the Director, Clinical Programs Strategy at Nova Healthcare Administrators, Inc. in Buffalo, NY, where she focuses on identifying opportunities to control medical expense and ensuring benefits support health management strategies. Tatia has more than 22 years of experience in the health care industry, including nearly 18 years in managed care medical management, ensuring the appropriate utilization of services and improving the health status of members. Tatia holds a nursing degree and is certified as a case manager, corporate wellness specialist, and certified managed care nurse. She is also an active board member of the Buffalo New York Chapter of American Diabetes Association.

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